Stop Loss Claim Auditor

Valenz•Phoenix, AZ

2d•Remote

About The Position

The Stop Loss Claim Auditor reviews and audits stop loss reimbursement requests to ensure accurate and timely payments in accordance with plan documents, stop loss policies, contractual requirements, and established procedures. The role evaluates claim and eligibility documentation, performs aggregate claim calculations within delegated authority, and supports plan-document reviews, payment integrity initiatives, reporting, and high-cost claim monitoring. The position retrieves and reviews claim submissions, audits initial and supplemental reimbursement requests, and performs preliminary audits of aggregate accommodations and year-end aggregate claims. It identifies discrepancies and potential issues, escalates matters outside its authority, maintains accurate audit records, and communicates with internal and external partners. The role also reviews plan documents using established checklists and approved automated or AI-assisted tools, validating outputs before they are used in decisions. This is a fully remote, US-based position. The employee must have a quiet, distraction-free workspace, reliable internet, and follow company security protocols, including use of VPNs, secure passwords, and approved devices and software. Necessary equipment will be provided.

Requirements

3 or more years of experience in healthcare claims, stop loss claims, medical claim auditing, TPA operations, or a related field.
Working knowledge of self-funded medical plans, employer stop loss terminology, reimbursement processes, contracts, and operational workflows.
Ability to interpret plan documents, stop loss policies, eligibility information, and claim documentation.
Strong analytical and mathematical skills, including the ability to perform detailed claim audits and reimbursement calculations accurately.
Strong attention to detail and ability to maintain complete, accurate, audit-ready documentation.
Ability to independently review claims within established procedures and delegated authority and appropriately escalate exceptions or high-risk matters.
Strong organizational and time-management skills, including ability to manage multiple claims, deadlines, and documentation requirements.
Strong written and verbal communication skills and ability to work effectively with TPAs, carriers, brokers, vendors, and internal partners.
Proficiency with Microsoft Office applications, including Excel and Word, and ability to learn stop loss administration, underwriting, and reporting systems.
Ability to use approved automated and AI-assisted tools responsibly while maintaining appropriate human review and validation of outputs.
Ability to handle confidential financial, claim, and member information with discretion.
US-based and able to work in a location that complies with company policies such as HIPAA.
Quiet, distraction-free workspace, reliable internet connection, and adherence to company security protocols.

Nice To Haves

Bachelor’s degree in Healthcare Administration, Accounting, Finance, Insurance, Business, or a related field.
Experience auditing complex or high-dollar medical claims.
Experience reviewing Summary Plan Descriptions, plan documents, stop loss contracts, or amendments.
Experience with aggregate accommodation and year-end aggregate claim calculations.
Experience with self-funded employers, stop loss carriers, TPAs, managing general underwriters, or related healthcare financing organizations.
Experience identifying payment-integrity, cost-containment, subrogation, coordination-of-benefits, or eligibility issues.
Experience with stop loss claims administration, underwriting, or reporting platforms.

Responsibilities

Retrieve, log, organize, and review stop loss claim submissions and supporting documentation within established turnaround standards.
Audit initial and supplemental reimbursement requests for eligibility, covered expenses, contract terms, deductible application, and other applicable plan and policy provisions.
Perform preliminary calculations and audits for aggregate accommodations and final year-end aggregate claim submissions, reviewing contract terms, aggregate factors and deductibles, enrollment and premium information, paid claim data, and supporting documentation.
Identify discrepancies, exceptions, ambiguous contract language, and matters outside delegated authority, and escalate them to appropriate Claims, Compliance, Underwriting, or leadership resources.
Obtain and evaluate supporting documentation, including eligibility records, extension-of-benefits information, FMLA and COBRA documentation, precertification information, accident or subrogation records, UB-04s, itemized bills, and other required materials.
Maintain complete and accurate documentation of audit activity, information requests, calculations, determinations, and supporting records within applicable claim systems.
Review plan documents, Summary Plan Descriptions, amendments, and related materials using established checklists and approved automated or AI-assisted tools.
Validate automated or AI-assisted review outputs before use in claim or plan-document decisions, and escalate material discrepancies or uncertainties for additional review.
Identify potential eligibility, coordination, cost-containment, payment-integrity, or reimbursement issues and coordinate with appropriate internal and external partners.
Support high-cost claim monitoring, reserve and notification review, and related reporting by evaluating available clinical and financial information.
Communicate with TPAs, brokers, carriers, auditors, vendors, and internal partners regarding missing documentation, claim status, audit findings, and related questions within established authority.
Support claims quality reviews, reporting, research, procedure documentation, and continuous improvement initiatives.
Provide backup support for claims intake and workflow activities as business needs require.
Perform duties in accordance with established procedures, contractual requirements, delegated authority, confidentiality standards, and applicable regulatory requirements.

Benefits

Generously subsidized company-sponsored medical, dental, and vision insurance.
Access to services through Healthcare Blue Book and KISx Card.
HSA, FSA, and DCFSA spending account options.
401(k) with company match and immediate vesting.
Flexible working environment.
Generous paid time off, including vacation, sick leave, and paid holidays.
Employee Assistance Program with professional counseling, referrals, and additional services.
Paid maternity and paternity leave.
Pet insurance.
Employee discounts on phone plans, car rentals, and computers.
Paid time off for philanthropic endeavors.